2023 Theses Doctoral

The Monogenic Architecture of Retinal and Neurological Diseases

Lee, Winston

Monogenic diseases, or single-gene disorders, are clinical manifestations that can be traced to genetic variation in a single gene that alters the biologically intended (wildtype) function of its protein (or mRNA) product. Although the causal gene and its function are well-understood in many monogenic diseases, this knowledge alone often does not fully encapsulate the extensive clinical spectrum of phenotypes seen in patients. This is due in part to the numerous types of pathogenic variants that can arise in a single gene, all of which can have distinct effects on disease expression. Understanding the relationship between the vast number of possible genotypes and corresponding disease phenotypes defines a gene’s monogenic disease architecture—an important but poorly understood concept that can yield informative mechanistic and clinical insight.

This doctoral dissertation integrates traditional sequencing approaches with in-depth characterization of patient phenotypes to elucidate the monogenic disease architecture of three etiologically distinct disorders: retinal degeneration caused by autosomal recessive variation in ABCA4 and neurodevelopmental disease entities caused by autosomal dominant variants in CERT1 and PUM1. Genetic modifiers are identified as a significant factor in the penetrance of the major disease-causing allele of ABCA4 and several other genetic inconsistencies are resolved to create a coherent genotype-phenotype model for the disease. Insight from this model is then applied to demonstrate the effect of allele differences in disease progression and evaluation of treatment efficacy in patients. A large cohort of affected individuals with CERT1 variation is assembled to (1) validate the causal role of CERT1 in disease, (2) delineate the precise mechanism of CERT protein dysfunction in sphingolipid metabolism and (3) demonstrate therapeutic efficacy of an inhibitor compound for a newly described syndrome.

Finally, the mutational spectrum of PUM1 is expanded to previously unattributed variant classes with unexpected pathophysiological consequences to patients. Not only do the findings in this dissertation advance the prospects of delivering personalized, precision medicine to patients, the overall impact underscores the importance of this integrated approach in reconciling knowledge gaps between observations at the molecular and organismal level.